2018-19 Dharma School Registration
Youth's First Name *
Your answer
Youth's Last Name *
Your answer
Youth's Birth Date *
MM
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DD
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YYYY
Gender *
Your answer
Grade Entering 2018-19 School Year *
Your answer
Parent/Guardian First Name *
Your answer
Parent/Guardian Last Name *
Your answer
Parent/Guardian First Name
Your answer
Parent/Guardian Last Name
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Parent/Guardian email *
Your answer
Parent/Guardian Phone *
Your answer
Parent/Guardian email
Your answer
Parent/Guardian Phone
Your answer
Are you currently a member of Dharma Rain or Zen Community of Oregon?
When you make a pledge of $15 or more per month, you receive the benefits of membership. Membership benefits include: reduced fees for Dharma School, reduced fees for many other programs including sesshin, use of the library and the right to vote during Board of Director elections. Go to https://dharma-rain.org/getting-involved/membership/ to learn more about membership and become a member.
Current Membership *
The next two questions are for youth and families
We understand that this is a Buddhist Sunday program and we want to have some fun while learning to do Buddhist practice. *
We have been learning about Buddhism at home and/or at a temple *
In case of emergency, parents/guardians will be notified first. Please list two ADDITIONAL emergency contacts.
Emergency Contact #1 Name, relationship and Phone Number (NOT Parent/Guardian listed above) *
Your answer
Emergency Contact #2 Name, relationship and Phone Number (NOT Parent/Guardian listed above) *
Your answer
Does the youth have medical insurance? *
Does the youth have dental insurance? *
Health History: Does the young person have a medical or mental health condition that a doctor or medical professional should be informed of in case of emergency? Please be specific. *
Your answer
Drug allergy? If yes, please describe. *
Your answer
Food allergy? If yes, please describe. *
Your answer
Chronic or recurring illness? If yes, please describe. *
Your answer
Need to take medication regularly? If yes, please describe. *
Your answer
Other: Please tell us of any special concerns you have about the youth's comfort and what might interfere with the success of Dharma School experience. We would appreciate insight into the strengths, weaknesses, and/or idiosyncrasies of the young person's character and physical being. *
Your answer
The youth may be given any and all medical treatment deemed proper and necessary by an attending physician in case of emergency. *
I understand that pictures and videos may be taken during Dharma School or other Dharma Garden programs. I hereby give permission for the use of such images of my youth for the promotion of Mandala on the Mountain and/or Dharma Rain Zen Center. I understand that children are never identified by name in publications, unless by express permission of the parent(s)/guardians(s) (and child, if old enough to object). *
Please include our family's information in the Dharma School Family Directory. The Directory will list names of parents, children, class groups and email addresses of parents. Inclusion in the Dharma School Family Directory is optional.
I have filled out this form fully and accurately to the best of my knowledge. I agree to release Northwest Zen Sangha, Dharma Rain Zen Center, and the staff of Dharma School from any liabilities that might accrue from reasonable and normal activities during the time my child is in their care. My questions about Dharma School, Dharma Garden programs, and/ or overnight participation have been satisfactorily answered.
Name of person filling out this form, and date *
Your answer
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